REQUEST FOR INFORMATION

PRE-EMPLOYMENT ALCOHOL/DRUG TEST REQUIREMENTS

Texas Department of Criminal Justice

Labor Relations Section, Human Resources Division

2 Financial Plaza, Suite #600, Huntsville, TX 77340

Phone: (936) 437-3171 Fax: (936) 437-3105

TO BE COMPLETED BY COMMERCIAL DRIVER: You shall provide the following information for each employer you have worked for in the past two years. Complete only this section, and complete a separate form for each employer. Sign this form on the back side where indicated, and return this form to the SCO, Labor Relations Section, Human Resources Division.
Date:
(MM/DD/YYYY)
Employee Name: / Employee SSN#
Previous Employer Information:
Name / Area Code/Phone Number
Mailing AddressCityStateZip Code

TO BE COMPLETED BY PREVIOUS EMPLOYER:

The above named individual has been hired as a commercial driver for the Texas Department of Criminal Justice. This individual has given your name as a former employer. Pursuant to 49 CFR §§ 382.405(f), 382.413, and 382.401(b), please complete the following information and fax the completed form to (936) 437-4010. Your assistance is appreciated. See the reverse side for the “Release of Information” authorization. Failure to furnish information as requested by 49 CFR §§ 382.405(f) and 382.413 is a violation of D.O.T. regulations and may result in a fine and/or civil liability.

1. / When was the individual employed by you? From: / to:
2. / Individual’s position with your firm:
3. / Which one of the following applies? / Still employed / Laid off / Fired
Resigned with proper notice / Resigned without proper notice / Asked to resign
4. / Reason for leaving:
5. / Is the individual eligible for rehire? / Yes / No
6. / Did/does the individual participate in the D.O.T. alcohol and drug testing program? / Yes / No
7. / Does the program conform to the federal regulations noted above? / Yes / No
8. / Did the individual refuse to be tested for alcohol and/or drugs, including having verified
adulteratedor substituted drug test results? / Yes / No
9. / What was the most recent date the individual was tested for alcohol and/or drugs?
10. / Has this individual ever tested positive for a controlled substance in the last two years? / Yes / No
11. / Has this individual ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years? / Yes / No
If an alcohol or drug test was positive, information shall be provided regarding the individual’s previous evaluation by a
substance abuse professional and compliance with recommended treatment:
12. / Has this individual violated any other U.S. D.O.T. drug and alcohol testing regulations? / Yes / No
If yes, please explain:

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PREVIOUS EMPLOYER’S COMMENTS

Completed By:
Printed Name: / Last / First / MI / Signature / Date (mm/dd/yyyy)
Title / Area Code/Phone No.

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

AUTHORIZATION FOR THE RELEASE OF PERSONAL INFORMATION

I do hereby authorize a review of and full disclosure to the Texas Department of Criminal Justice of all information and records concerning my employment with any person, employer, or company, whether said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records of any previous employer or sponsor, to include employment and pre-employment records, any alcohol/drug test results, any refusals to be tested by me or participation in any alcohol/drug abuse programs.

I understand that any information obtained by any background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization shall be considered in determining my suitability for employment as a commercial driver by the Texas Department of Criminal Justice. I also certify that any persons, employers, or companies divulging such information concerning me shall not be held accountable for giving this information; and I do hereby release said persons, employers, or companies from any and all liability.

Commercial Driver’s Signature
Printed or Typed Name
Date
Note to Employee Commercial Driver: With few exceptions you are entitled upon request: (1) to be informed about the information the TDCJ collects about you; and (2) under Texas Government Code §§ 552.021 and 552.023 to receive and review the collected information. Under Texas Government Code § 559.004, you are also entitled to request in accordance with TDCJ procedures that incorrect information the TDCJ has collected about you be corrected.
TO BE COMPLETED BY THE TEXAS DEPARTMENT OF CRIMINAL JUSTICE
This form was sent to the previous employer via (check one): Fax MailDate Sent:

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